Transatlantic Tales of a Certified Anesthesiologist Assistant ft. Mark Leonard, CAA

In this first PROCESS interview of 2024, I sit down with the extraordinary Mark Leonard, whose career leap from the UK's Anesthesia Associate to an American Certified Anesthesiologist Assistant is nothing short of inspirational. Mark candidly shares his insider knowledge on his significant roles within the CAA profession, from his hands-on clinical work to spearheading simulation program development and teaching regional anesthesia to CAAs. This episode isn't just Mark's personal story; it's a treasure trove of insights for anyone in the anesthesia field or anyone contemplating a big life change. 

Mark encourages all CAAs to find their unique path to support and strengthen our rapidly growing community, remembering that sharing knowledge is just as important as acquiring it. This conversation is a testament to that belief. So, tune in for an enlightening exploration of the paths that shape our professional lives and the communal bonds that fortify them.

What did they say? KEY:

• ODP (Operating Department Practitioner- UK)
• AA (Anesthesia Associates- current name for CAAs in UK)
• CAA (Certified Anesthesiologist Assistant- USA)
• ANAESTHETISTS (UK- Anesthesia Doctor)
• ACT (Anesthesia Care Team)
• LAST (Local Anesthetic Systemic Toxicity)
• TAP (Transversus Abdominis Plane block)
• GA (General Anesthesia)
• NCCAA (National Commission for Certification of Anesthesiologist Assistants)
• NOVA/NSU (Nova Southeastern University- AA Program)

Resources Mentioned:

• @anesthesiaanonymous TikTok
• CAALifestyle YouTube
• AnesthesiaSal YouTube
• AnesthesiaOneSource.com
• Ultrasoundexperts.org
• 8 blocks every CAA should know- interscalene, supraclavicular, femoral, adductor canal, popliteal sciatic, TAP, rectus, erector spine plane (ESP)

Connect with Mark @ ML2268@nova.edu
Mark Leonard FB

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Chapters

• 0:00 Rapid Fire Round
• 17:18 How prospective AAs can stand out
• 26:55 Evolution of Anesthesia Associates in the UK
• 38:09 AA students rotating in the UK
• 47:29 Expanding Regional Anesthesia Education for CAAs
• 55:45 Promoting regional anesthesia education and practice for CAAs
• 1:05:27 Can CAAs work in the UK?
• 1:18:20 How to Make Change as a CAA
• 1:24:00 How to Connect Further

Transcript

Speaker 1: 1:14

So now we are not the best job that nobody knows about. Now we're the best job that an awful lot of people know about.

Speaker 2: 1:24

Welcome to the Awakened Anesthetist podcast, the first podcast to highlight the CAA experience. I'm your host, mary Jean, and I've been a certified anesthesiologist assistant for close to two decades. Throughout my journey and struggles, I've searched for guidance that includes my unique perspective as a CAA. At one of my lowest points, I decided to turn my passion for storytelling and my belief that the CAA profession is uniquely able to create a life by design into a podcast. If you are a practicing CAA, current AA student or someone who hopes to be one, I encourage you to stick around and experience the power of being in a community filled with voices who sound like yours, sharing experiences you never believed possible. I know you will find yourself here at the Awakened Anesthetist podcast. Welcome in. Hello all my fellow CAAs, aa students and anesthesia colleagues, this is your host once again, mary Jean. You know I love these process episodes and bringing them to you, so let's kick off things like we do all things medical, with a quick timeout. My guest today is Mark Leonard. Mark has been an AA since 2008, but for his first 10 years as an AA, he was living and working in England and he wasn't technically an AA as we know them in the United States, but an anesthesia associate, which was a UK-based mid-level anesthesia provider based off of the American CAA model taken from Emory University, and Mark goes into way more detail about how this all went down. We start that conversation at about 19 minutes 25 seconds. If you want to fast forward and get all of the info then and then go back and listen to the beginning, it actually might help clarify a few things. If this is a completely new idea to you, as it really was to me but after Mark decided to move to the United States in 2018, he became an American CAA through a Nova Tampas program and he currently lives and works and teaches in Tampa, florida. Mark works clinically as a CAA three days a week. He works 13-hour shifts those three days and does mostly thoracic cases at his HCA hospital in Tampa, and the other two days a week he works as the director of simulation for Nova Tampas AA program. In addition to that, he teaches a full-service regional anesthesia course for all the Nova programs. You will hear Mark's passion for regional anesthesia and how that all came to be in this episode as well. So he teaches that course for Nova Tampa, nova Fort Lauderdale, jacksonville, denver and the soon-to-be-Nova Orlando program and, if that wasn't enough, mark also runs regional anesthesia and vascular access courses with the Tampa-based company ultrasoundexpertscom. This truly expansive and kind of crazy different story episode is going to expand any practicing CAAs who want or need to work abroad, any AA students who want to do a rotation abroad and NEA students or CAAs who have big dreams and want inspiration to just get out there and take that first step towards making it happen. I'm so excited for everyone to get to know Mark Leonard. He's truly an amazing human being and CAA and I hope you enjoy this process episode. I'm just really excited that we connected because you have such a unique CAA journey that I think is really expansive and also just really interesting and going to answer, I think, a lot of questions that some CAAs have in their mind. I feel like you've lived some of these answers and can kind of give us a little bit of advice, so I would love to first jump in and start with a rapid fire round to get to know you a little bit better, if that's okay.

Speaker 1: 5:35

Okay, yeah, far away.

Speaker 2: 5:36

Okay, first one, let's start light. What's the best show or series that you've watched lately?

Speaker 1: 5:43

Oh my gosh, I'm not a huge TV watcher, which is disappointing to my wife. What did we watch recently? We watch a lot of kind of like real life drama things. I don't even think like my wife's rewatching this is us.

Speaker 2: 5:59

Well, drama, little family drama.

Speaker 1: 6:00

Mark, so I've started watching that. So I suppose that's kind of the main thing. But if I watch TV I'm watching football games.

Speaker 2: 6:07

Okay, respectable, are you an extrovert or an introvert Mark?

Speaker 1: 6:12

Okay, well, it really depends on the situation, but I suppose I'm quite extrovert and have to be kind of in our position and my position that I hold.

Speaker 2: 6:21

Yeah, what time do you go to bed and what time do you wake up?

Speaker 1: 6:26

So I like to be heading to bed for about 9.30 so I can be asleep by 10. I have palpitations if the time runs on. Last night I was watching the books game, so it was after 11, so I was like, oh, this is going to be terrible, and I'm normally awake around about 5, between 5.30 and 6.00 am depending.

Speaker 2: 6:44

Is that to like get up and immediately go to work, or do you like to have a slow morning?

Speaker 1: 6:49

I like to get up, drink tea and then my wife has to get up. We've got two children so we have to get them ready to go to school. So that's a process trying to wake a 12 year old up every single morning. So yeah, so I like to help her in the mornings.

Speaker 2: 7:05

You just gave us a little glint of the answer to my next question, which no stereotypes, but I'm wondering if you're a coffee or possibly a tea person.

Speaker 1: 7:13

I'm definitely a tea drinker Twining's English breakfast tree or tea or Twining's everyday tea. So I'm definitely a UK traditionalist tea drinker. Apparently there was a whole war about it, but I don't talk about it much in the UK.

Speaker 2: 7:28

What goes into your tea, because it's not just black tea.

Speaker 1: 7:31

No, so we drink hot tea. I do drink iced tea as well. I'm a big fan of iced tea with lemonade, and I will drink my tea hot, with milk and sugar.

Speaker 2: 7:42

I see, okay. Well, let's see here One last thing from the tea and your accent, I think possibly we've all gathered that you're from the UK, so I'm just wondering, now that you live in Florida, what's the thing you miss most about living in England?

Speaker 1: 7:58

I mean I'll say fish and chips, but I suppose my family as well, because they're still there. So, but certainly some food stuff, although I have. You know, I'm not like the usual English person that moves to America and wants to make America Britain again. I've settled into the US lifestyle, but there are some food stuffs that I do miss.

Speaker 2: 9:36

Now I'm interested what you think the biggest difference in American lifestyle versus UK lifestyle is.

Speaker 1: 9:42

Oh gosh, I mean, I suppose for me it's really that kind of outdoorsy thing. I live in Florida, so my family lifestyle is very, very outdoors. You know, when I lived in the UK I didn't have a pool. It wasn't, you know, in the 70s, over the winter, so you couldn't go out on your bicycle or play football in the street, or so I think it's a very, very different lifestyle for my family. It's a great environment to bring up my younger children. So yeah, I suppose, that's the main. I mean, there's many other differences, but politics is politics, religion is religion. So you know all of those things kind of. It doesn't matter where you are in the world you can have those things, but. I suppose, lifestyle is different.

Speaker 2: 10:25

That sounds like a good change. I'm proud of the US, that it wasn't some horrific, awful thing that you were going about to say.

Speaker 1: 10:31

Oh no, absolutely not.

Speaker 2: 10:34

All right, tell us a little bit more about your upbringing as a child and your cultural background, to give us a real sense of who you are.

Speaker 1: 10:42

Okay, so I was born in 1971. So I'm an old guy. I was born in Bournemouth, in Birmingham. Birmingham is home of Peaky Blinders, so if anybody watches that series, we're not all gangsters like that, but we do all look like like the characters. Bournemouth is famous for Cadbury's chocolate, so I was a Cadbury's kid. Both my parents worked at Cadbury's George Cadbury when he started Cadbury's. They were of a Quaker faith and they were very, very great believers in family values. So if you got married whilst you worked for Cadbury's you were given a rental house. So my mom still lives in that original house from 54 years ago. Everybody had huge yards, big lots of green space and parkland, open areas for people to exercise and do things. But growing up as a teenager you want more things to do and the Quaker religion I'm not a Quaker background, but the Quaker religion no license premises. Those family values meant stores not being open 24 seven etc. So it got pretty boring as a youth in my teenage years and we would start to get into trouble. You know we'd want to. We just gangs of kids would sit around in the parks. So inevitably when you get to an age where you can get somebody to buy drink for you. We'd be drinking Budweiser and carrying a, I would remember a 3D superwaffa stereo around stereo, typically listening to the Beastie Boys and Run DMC and whatever other rap music at the time, thinking we were like Americans, you know, shotgun in Budweiser cans and generally getting into trouble, and I thought, well, yeah, not so bad. I said I kind of thought that if that's not the life that I wanted, I'd always work. From when I was kind of 12 years old, I started working and always had a great work ethic and thought I need to get away from this, otherwise I'm going to fall into trouble and just never, ever leave Bourneville. And no disrespect to people and my friends and family that are all still within Bourneville, but certainly, from my point, I didn't want that. So I joined the military when I was excited, when I was 15, when I was 16, relatively short-lived career in the military had an accident and they didn't know what to do with myself. So I had a flitted around and I worked in a casino for a little bit, I worked in catering for a little bit and none of these things kind of you know, just jumped around trying to find my avenue but still trying to work, because that's always. You know, my whole kind of life was about working and providing for myself. I'm one of I was the oldest of four siblings. My parents were a very working class family. You know, if I wanted any designer clothing or anything I had to work for it because my mum would say I've got four of you to buy school shoes for. So if you want high-end sneakers then there's 10 pounds that I'd normally buy you sneakers, and if you want 50-pound sneakers you've got to put 40 to them. So that gave me the desire to work to buy nice things. Eventually I kind of stumbled into driving a little kind of mini van around with taking patients to and from hospital appointments. So our little old ladies and men go into their hospital appointments and I enjoyed that. But then worked my way up through that to start to become a medic. And then a lot of sporting medicines, so a lot of boxing, tie-fighting, motocross, car racing etc. And that was fun at the time but prohibitive in the respect that it was all evenings and all weekends and long hours. We traveled across the UK providing medical services. It didn't really fit well with my life then. And then in the UK, in Birmingham, we had a newspaper, the Birmingham Evening Mail, and if you wanted a job on a Thursday evening you would buy the evening mail and it would be full of advertisements and it would be broken down into automotive or electronic or and there'd be a medical section. And just I just read through it one Thursday and there was an advertisement that said an exciting career working in the theatre Now, not the theatre, as in Broadway. In the UK operating rooms are called the theatres. Historically, people would pay to go and watch an operation and they would sit in a theatre environment watching those, and just that name stayed there. I thought this sounds like fun and I'm not outside in the cold and wet and mud and driving around the UK. I could be working inside there. So I took a job as what was called then an operating department practitioner and then that led me into coming in as a, as a, as a mid level. There's a little process behind that, but yeah, that was my my route to getting into being an AA in the UK which I was not an AA to start with, it was a different name and then moving out to the States.

Speaker 2: 15:53

Hmm, hmm, I hear a question and also a comment, the. The comment is that I can hear in your journey how you had a little bit of a meandering path to finding the ultimate career that was meant for you, and I think you know there's two, two kind of sides of that. Like some people are still in that immediately high school, then college, then grad school, then working, and like it's this rush, rush, rush, go, go, go. And then I think there's this other group, that kind of meanders and find there's finds their own way to see a. So I wanted to hear your comments on that. And then I also wanted you to just paint a little bit of a picture on your educational background up to that point, because I'm not familiar with how that works in England.

Speaker 1: 16:37

Okay, what do the education first of all. So UK education is very different from the US education. So, as I said, I would kind of list it to the military when I was 15 and during when I was 16. So you could leave high school at 16. It's changed somewhat now that if you don't have a position to go to then you stay in high school till 18 in the most parts, but you would least go very early. You know, 16 years old is very young to go off and do something, to take an apprenticeship or stay in school to do what would be known as a levels in the UK. So it's really balanced levels. So that education somewhat different. I always knew I was going to join the military. Whatever I was going to join the military in. I wanted to join military police and they told me that wasn't such a good place to be. So to join the infantry, which was at 15 years old, was the worst advice anybody had ever given me. But I knew I wanted to be a soldier. So that's what I did. I signed up. So I didn't go crazily doing my exams and trying to kind of be a GPA of four student. I did well enough, but not fantastic. And of course when I left the military I was kind of at a loss because I didn't have any other route to go. So that background of kind of trying to find my way was different. I want to come back to that in a second. And then the route to get into the UK was somewhat different in the respect that the entry into the UK was not like it is here with the prerequisites etc. Etc. And because I'm a merit of your experience, what was going on with you as a person personally at the time and then interview etc. And then to go to the university to do the degree. And again, the degree was slightly different. It was called a postgraduate diploma with a master's option bolted on to that. So not everybody had to come out with a master's. If you didn't want to, there was a research dissertation to do as part of your master's service. So that was kind of the educational background to get into that. But still, the way that it is now across the universities that are running the course. Some universities are now off through a full master's program as part of that, but it's still for the most part 27 months. I've even come out with that kind of postgraduate diploma, which is a higher degree In terms of kind of the flitting around. Before coming into AI I didn't know what I wanted to do with myself. I came out in the military I was over a loss. I've done all these other little jobs, trying to just earn some money and do things, but not knowing what I wanted to be or who I was. I'm going to stumble into driving my little minivan around with my elderly population taking to their appointments. I was a young guy in my early 20s and then all of a sudden you're thrust into this group of 70, 80, 90 year olds that you maybe have nothing in common with and you have to find the common ground. So you very quickly learn communication. We would drive around listening to 50s and 60s radio stations and listening to regaling stories of how they worked during the wars, etc. And I honestly believe that maybe a better person in terms of my communication skills and the way that I could deal with a multicultural population. You know you guys are very multicultural. So you know, on one minivan I could have someone from the UK, someone from Ireland, a Pakistani, so a Jamaican, Everybody would be bundled together. So learning those different cultures and language differences etc. I think it was a great benefit for me and I don't want to be disrespectful to any of the students that come into the program because, as faculty, I interview these people. But I can absolutely see a clear demarcation from people that have had some sort of background, whether that be that they have worked before or worked while they were doing the undergrad. So I can still get the younger students that come into the program that maybe have worked at service or as servers in a certain unit. A catering environment is normally where we find and we find those people have had to have great communication skills, otherwise they're not getting their tips and they're not earning their money. Or likewise, people that have worked in a customer service environment is very good at dealing with people and how to communicate, and we all know communication is absolutely keen in our position in that tiny amount of time that we get to deal with our patient, I'm a great believer that I think that a little bit of kind of background skills you know there are some like my bigotty views that I think that people should have a little bit more experience before they come into a program, even if they just volunteer for six months as a patient volunteer a school and patients to and from departments etc. And helping out will give them a great, great understanding of patients, communications, the way that the healthcare system works.

Speaker 2: 21:44

Yes, I noticed that too, that it's almost intangible. You can't quite put your finger on why a first year student just feels so much more confident like it portrays as confidence when you have that interpersonal communication skill. And that's interesting because I too think that it is that exposure I mean it doesn't have to be in healthcare, but that exposure to talking to different types of people, being in uncomfortable situations and having to, you know, like still listen and speak and respond and like hold yourself in a way that, like you know, just I think is a skill, is something that needs to be practiced. So that's interesting, that you feel like that's what that time gave you. And also, I think, interesting if you're a prospective AA, listening right now and wondering what's something I can do to really beef up my application is maybe getting a job like that that lets you use your interpersonal skills and then say I intentionally did this because I think it's important as an AA to have really high quality interpersonal communication. I think that would be like oh wow, you've really thought about this, you know.

Speaker 1: 22:53

Absolutely. I mean, I'm a great advocate of people. I think what we, what we're trying is what we're tending to see, is two different streams of people coming into the profession and the people that say Well, my shadowing forms is I need to do eight hours, so I'm going to do eight hours. Yeah, if you want to base your whole life life choice on eight hours of studying in an OR, depending on where you go, depending on who you are, where you might be sat in the corner, you may just be there just to get that full sign for your eight hours. Or we get our other people that are regularly shadowing and you know they'll be like oh, I've done 100 hours now. Do you think that's enough? And I'd like, okay, well, I think that's a pretty good amount of hours to kind of base your decision on. So, yeah, I'm a great believer that people need to. This was just going to jump into something else that I'm not coming always used to be this is the best job nobody knows about. So that's how it was. You know, when you would interview people, you would say how did you hear about this? And it would really be. Oh, I was at a party and attended a friend's girlfriend. I knew I was doing this in undergrad and they did this. They told me about it, and then I looked into it, I did my research and blah, blah, blah. Now, of course, we have some amazing access to our program. You know, the work that you're doing with the podcast is fantastic. The work that people actually pay them a man's thesis salad. Do you know? They're on social media. We were, you know we were lazy. My generation was lazy because didn't promote our role. No, we didn't promote our role. Now people are coming forward to say what was up, let's do this. What that has done, though, is opened up our role, so now we are not the most you know the best job that nobody knows about now with the best job that an awful lot of people know about. So that market to get into the AI program is very, very competitive. So, as a prospective students that maybe listen into these people that want to get into the program, we've got to make yourself marketable. You've got to come to interview, and those communication skills are going to really kind of stand out in interview lives. We can read from the references and as a recommendation, et cetera, that we've been given this. We can read that out of the interview and I like to see the people have done things. I like to see the people have worked. I've worked from 12 years old. I'm self sufficient for a long time, so I like to see people that have had the battle and kind of been working and have that mindset, as opposed to the other mentality that maybe watched some videos that have resurfaced recently about how much money that we earn and how fast you can pay off student loans and then think, hell, I'm going to do that because it's a financial decision.

Speaker 2: 25:36

Mm. Hmm, yes, yes, thank you for speaking directly to that perspective A A because, yeah, that it's the perspective A? A audience is quickly outnumbering the A? A audience, like you know, the people who are looking for that information. So thanks for offering your wisdom there. I wanted to transition us into really drilling down this idea of CAAs, which I don't want people to get hung up on the abbreviations or the acronyms, although it is very confusing, because I just want to call out that in England there is oftentimes a parallel anesthesia provider to what is in the United States, but it is called something different. So Mark and I are going to be speaking kind of like parallel language. I'm going to create a little bit of a key in the show notes. So if you're listening to us right now and you're a little confused of what I'm talking about or Mark's talking about, and if we're using acronym you're not familiar with, go to the show notes. But I do want Mark to describe how there are AAs or an AA equivalent working in England right now, and that is how Mark came to the United States, like a hop, skip and a jump. So take us back to England trying to find mid-level providers and how they landed on AAs.

Speaker 1: 26:55

So it was almost traditionally a physician-delivered service in the United Kingdom and they would be a methodist, so junior doctors. Medical school was five years in the UK. So they would do five years at medical school, then come out of medical school and then go through their training. Now here we're obviously called residency In the UK. They would be trainees and the trainees went from CT core trainees to ST, which was specialist trainers. So core trainees would do the different medical specialties and move around, hop, skip and jump around those different specialties and then they would choose anesthesia as their profession and then be ST trainees. So that was a seven-year process. That was without them doing any sort of fellowship. So then if they wanted to do a year's fellowship or in KFC care or regional anesthesia, that would add on to that. So it was kind of a minimum of around 12 years from starting medical school to be a physician and then they would become a consultant, a methodist. So, they don't call themselves anesthesiologists in the UK. But back in the late 90s they looked and saw that the amount of numbers of people entering anesthesia were dwindling and we had an aging population. We're victims of our own success by medicating and making people live longer because of medication, healthcare etc. So in that respect, more people buy into the healthcare service, so there's an increased demand for that. Anesthesia in the UK was also a very female populated specialty, so a lot more females were entering anesthesia. Now females have one thing over a male if you choose to have a child or not. And in the UK you can take 12 months off if you have a baby Very different to the US and nine months of that 12 months would be paid. So exactly. So what would happen then is obviously, whilst you are maternity need, there will be a shortage of providers. So they needed a kind of a continuity of while you were training you would move around from hospital to hospital. So the continuity was going to come in the way of introducing a mid-level service. So in the late 90s they started to look at that and they looked around Europe where there were a few different countries kind of experiencing and utilizing advanced practitioners to work alongside anesthesia, but predominantly they came back to the US. In the UK we have a Royal College of Anesthetists or Anesthetists, as we said, because we put an X-ray in there and we have the Royal College of Nurses and then we're working together to look at providing an anesthesia service. Now, of course the Royal College of Nurses said we need CRNAs, so we need to do it down the nursing ground. And the anesthesiologists or the Anesthetists in the UK were like, well, in the US we've kind of they've partied ways. There's two specialties, you know, there's a little bit of fraction between them. So what can we find? And they stumbled upon the AA program and ultimately, through Emory University, they created what were anesthesia practitioners in the early 2000s. So that was when the program started. What they did was they took two Swiss anesthesia providers, bought them to the UK, bought them into an area in the UK that was very different to their mountainside residence, that they lived in Switzerland and saw how that program would work. And then those two people were the first two people, alongside a handful of others, that they entered the program In the UK. Then in the early 2000s the government said well, we're going to help support this kind of new profession that's going to help our anesthesia services. We're going to pay for it. So if you are a hospital and you won anesthesia practitioners as we were at the time we will give you the money to pay them a salary, to pay their university fees and to kind of give them a job afterwards. So a lot of hospitals were like well, I think it's cost neutral to us, we may as well do it and see the benefit of that. So they did that for five years when the government was funding the money. And then after five years the government said okay, you're on your own and you can pay for it now. And we have a nationalized health service that has to kind of penny pinch every nickel and dime or penny and pound in the UK. And they said well, we don't want to spend all this money on training these people live. So training numbers dropped from what wasn't a lot of training numbers so certainly much smaller than some of the class sizes in the US down to maybe two people a year being trained. So it kind of the market dropped out of it for a short time. Now there's been a resurgence and again the government are refunding this part of that on the back of PAs also coming to the UK and then wanting to run a physician extender program between how they are now in the UK, the NPA, aa, sorry, and the NPA. So my name changed three times. When I was in the UK I was an anesthesia practitioner and AP and then we realized that different specialties were calling themselves anesthesia practitioners, so assistants, like medical anesthesia texts in the UK, were calling themselves APs. So we changed the title because at that point then in the mid 2000s, we were bringing physician assistants over. So we changed our title to physician assistant anesthesia and that's what we would do. The physician assistants arrived in the UK and the physician assistant said hell, we are an assistant, we're associates. We don't want that assistant Monica. So they immediately rebranding themselves as physician associates in the UK and then Us as physician assistants. Anesthesia Rechanged our names to anesthesia associates. So now we have PAs, physician associates, aa, anesthesia associates. I mean in the US. The PAs have just kind of going through that name chain for physician associate in the US.

Speaker 2: 33:18

You've hit on such a pain point here in the United States, which is our name. For a very long time Our name was anesthesiologist Assistant and then in my career and I don't know the year to this, maybe I'll find that out but in the show notes we changed to certified anesthesiologist Assistant with the hope that we would all start introducing ourselves, maybe as our full name, but at the very least as a CAA, because there's been so much Distain for the fact that we have assistant in our name. I'm wondering, since you went through three derivations of a name, how much weight do you think it actually holds that our name is CAA, anesthesiologist assistant and whether we should really be pushing for a name change and if that's even possible, if the PA is just it, I guess.

Speaker 1: 34:10

Yeah, I mean this. The assistant title is definitely not representative of our role. You know, obviously it was a title that was bestowed on us For, I believe, medicare and Medicaid and a true background of how our title is, given that we became, you know, anesthesiologist assistants and the assistant money here who can be easily be used against us as a woodpecker and stick or that don't know us. And especially when we're going into new states to try it, getting licensure and go through legislation in new states, you go to somebody that sits in a house or sits on a board of something, can you say, oh, they are anesthesiologists, assistant, like okay, well, we understand an assistant. You look in the dictionary and you know what the title of an assistant is and I think it's it's very kind of Be know what our actual role is and not everybody understands that until we explain it and we don't have a chance or a time to explain that to our patients, we barely get five minutes to speak to them, to elicit their full medical history out of them without actually saying well, this is what I do, etc. And certainly some of our, our other anesthesia professions may use that assistant title against us. And you know, we've certainly seen. Maybe if we watch the Washington Videos from you know I'll push to be getting what a licensure in Washington at the moment, what a derogatory things are said about, you know, kind of using that. So when physician assistants came to the UK they were like, well, we're not assistants with physician extenders, that's an associate of the physician title. So they change their mind. And then in the US they just gone through that main challenge. Do I think we should? Absolutely I don't think that the assistant is a, a representative at all of our role or what we do. Do I think we can afford it? Possibly not at the moment. It's another thing that as a a's, we Maybe, once we've qualified and we just kind of go about our daily routine of working, we don't invest in our Organizations, our associations, to put money into that, that account to help us fight for these things. From what I believe it was, you know, maybe I'm well over a million dollars for the physician assistants to change their title to associate. We just don't have that money. And is it a priority to change our title or is it a priority to push to open more states in the US and more acceptance, acceptance, others? So if we could kind of flick a switch and change our title. I would all be for one, and you know, whatever we decided, our title would be as people that pay into our state membership should have a vote on what we think would be. I'd strengthen credibility and that certainly that system Can be used against us.

Speaker 2: 36:55

Hmm, yeah, I know so many people agree with you on all accounts there. I think it'll be really interesting to watch the PAs in the United States transition from physician assistants to physician associates and see how that goes as a roadmap for maybe something that we can do in the future. So thanks for bringing that up. I didn't know that PAs were transitioning their brand, their, their name, so I'll be now googling all that stuff. Okay, so you were working as an anesthesia associate, which was really a renaming, kind of a revamping of of CAAs taken from emery's us program, and you were working as such starting in 2008. And then I know that you came to florida. You were recruited to come to florida to do something very specific within the nova Tampa campus, and I just was wanting to hear that story firsthand from you of how you were brought to the united states and why.

Speaker 1: 38:02

Yeah, it's a bit of a crazy story, Um great so. I mean around 2011. We had a student from NSU fort lord that reached out to my association that was the association of physicians assistants anesthesia, the apaa in the UK and said hey, I'm an SAA in the US, in fort lord of dale. I've heard that your program is very similar to mine and I'd love to be able to come over and do an elective placement in the UK. Can it happen? So one of our associate association meetings we said, oh, this guy's email there, so he wants to come over. What do we think? So One of my colleagues from the uk sat on our association at the time and she said I think we could accommodate them. We've got a big hospital. We were a 44 hour hospital. We had a hundred anesthesiologists and almost a hundred trainees residents there, so we can accommodate a couple of Americans to come over and maybe they'll bring some candy and you know we can learn some stuff and that will be it. So this was around 2011, 2012, so I think in 2012, two SAAs from fort lord of dale arrived in the uk and we met them in the atrium of our hospital. You know, in the uk it's very different. You can't wear your theater blues or your oa. We call the fit, the or is the theater. In the uk Can't wear your theater blues outside of the or, so these two people are there in there Blues and you know we get the white coats on and there's stethoscopes around in it. It's still in the middle of a busy atrium with everybody looking at them like you. Are these people With? their fancy personal hats on and you know, that we don't do in the uk. We're very british, we can't wear our own hats etc. So that started kind of the relationship now if we just jump back a few years when I graduate. But when I qualified, my clinical service leave for my hospital said okay, well, greatly qualified, we're going to love having you guys around, but we don't have any work for you Because you can only do a, say one and two patients, which were the guidelines from the royal college of anesthetists at the time. And the hospitals kind of were two separate site hospitals, a level one trauma center which was at that time also the main military hospital dealing with Every single soldier that had been injured in Afghanistan from the uk and around the world. Um, you know, vascular surgery, big specialities, no real asa, one and two patients, and then the other or's in the other hospital was stacked so they were on top of each other. So then an anesthesiologist was like I'm not running up and down stairs trying to supervise a urology and then running down four flights of stairs etc. It just wasn't feasibly working. The only or's that were next to each other that worked were for hand surgery and predominantly the injuries there were from young, fit, healthy patients. So work related injuries you know, power tools, crush injuries, etc. Etc. So they said, well, the patient market fits the bill and the or's are side by side so you can work in the block room. And me, my colleague, who were the first two people that had qualified there, were like well, we learned some regionally anesthesia as part of our training, but we never really did a lot. So in about 2009, the military then come to us and said we need you to help. Without soldiers. They're all coming back blown to PCs, multiple Limbing injuries, very poor pain control for the mother than giving them you know how does high dose opioids etc. And but some of these soldiers are coming back from American hospitals out in Afghanistan With these nerve catheters and we don't really know much about them. So here's an ultrasound Can you learn how to use it? So the military provided us with our very first son or site and S nerve and nobody knew really knew how to use it. So myself and my colleague went the way to London on a course, on a residential course, to learn how to use it and then basically come back and honed our skills. And then we created, we move into a new hospital not long after that where we combined both of those hospitals Into one super hospital and we created a block room and the block room was amazingly active at buying for surgeons, the buying from residents. The trainees love to come through there and on a day to day basis that block room was was overseen by an anesthesiologist, a consort of anesthetists, but pretty much most of the anesthesia was delivered by Aase. So we were the people in there doing the nerve blocks under the supervision of an anesthesiologist and with trainee doctors alongside us. So we were doing a lot of research Alongside us. So we were doing Thousands of nerve blocks per year. Very different healthcare system in the uk with the, the national health service. So in the us our patients are like I'm paying my insurance, I want my ga? Um, you can give me a block for my pain relief. I want a percocet to take home, I want this, I want that. In the uk we have to fight every nickel and dime. So we're looking at our pennies and our pounds so we say, okay, well, you're not going to sleep, you're going to have a brachial plexus block and then you're going to lie awake on the table, we'll put the radio on for you and then afterwards we'll give you a cup of tea and some biscuits cookies and we'll send you home with a bag of painkillers for three days, and that's the way that it worked. And to start with, of course, patients will be like I'm not going to wait for my surgery. This is barbaric. So I got funding for iPads and noise-canceling headphones. So then we say, okay, now you can watch a movie. And then we developed the biggest block service in, I might say, the world, certainly definitely in the UK, certainly in Europe, maybe in the world where we were pushing thousands of patients per year through our block room for wide awake regional anesthesia, just done under ultrasound nerve block.

Speaker 2: 44:05

Wow.

Speaker 1: 44:06

So, then, we fast forward to back to 2012, when the Americans arrived they were like wow the students. The students, yeah. So the students were like, wow, we'd like to jump on board of this and we want to learn some ultrasound and some regional anesthesia. So they came to the UK for two months. They came to Birmingham, england, and then they went to Command and Shep in Wales, which is a little bit more than the UK is made up by England, northern Ireland, scotland and Wales. So those two hospitals would host them. So two students would come to Birmingham, then they'd move over to Wales and they predominantly were doing a lot of regional anesthesia. So when they came back to the US they had amazing skills. They'd been doing lots of blocks, lots of vascular access with ultrasound. So in the classes at the time there was Nova Tampa, nova Fort Lauderdale, so probably, you know, between 70 and 80 students per year. Six students came to the UK. So less than 10% of those students had great ultrasound skills. And that was obviously representative on the NCCAA Board exam where we got the breakdown of the specialties and who had done what. And regional anesthesia was an area where we were, you know, kind of less than either on average or less than average. So, dr Rob Wybner for anybody who knows him, dr Rob Wybner, who's the chair of the Department of Anesthesia for NSU reached out and said hey, rather than six students a year coming, why don't you come over here and teach 70 to 80 students to you, and then they will be all good at regional anesthesia? And my wife said no. And the next year, dr Wybner asked again and my wife said no again. And he went on and on and on until in the end, in 2017, dr Wybner said I want to speak to your wife, and anyone who's ever met Dr Wybner will understand he could sell eyes to Eskimos. He's a very, very key. You know, we call him the godfather of anesthesia down in Florida. He has a license number one in Florida, so he's been around for a long time. So he spoke to my wife. I was not there. I never know what was said, but amazingly, I got home after their conversation and she said hey, we're going to visit America. And I'm like what do you mean? She said we're going to Tampa in December 2017. I'm like we have no vacation time. We're selling our house. What is going on? So this was kind of in the June. So from June 2017 up until December 2017, we researched everything about the states. You know, we started talking to the NCCAA about qualifications, getting transcripts from universities backwards and forwards, and then, in March, the third, 2018, my wife, my two children, who were four and I don't remember their ages they were very young at the time and eight suitcases left the UK. With probably two feet of snow in the UK, we barely managed to drive our real wheel drive minivan down to London to get to the airport, and two adults, two kids and eight suitcases got off the plane. In Orlando, the heat hit us. We went to our Airbnb. My kids jumped in the pool. In March he knew in the US and that was it. We never looked back.

Speaker 2: 47:25

Wow, oh, my, oh gosh. I just you know what really strikes me about that story, which is not surprising to me now, but the person, the people who catalyzed that entire chain reaction, were the two brave Nova students who thought I wanna do something that's never been done before and I'm gonna go do it Like that's. Who started that whole thing, do you agree?

Speaker 1: 47:51

Yeah, it was like the domino effect of just literally writing an email. You know, this individual just sent an email and then there's a whole process behind that. So the other schools that are listening and students thinking, hey, I wanna go to the UK. Oh, believe me, it was not easy to set that up. Now. When the first two people arrived, we didn't know what to do with them. We didn't realize that they had kind of training, competencies, log book, achievements that they needed to do all of the specialities that they had to cover. Now we had 44 OIs in our hospital. We had everything except pediatrics and obstetrics, and obstetrics was doing at a sister hospital just across the street from ours, so they couldn't get access to that. We know what to do with them. Insurances you know who was giving them their insurance? Was it us? In which case, were we gonna let them do anything? Of course it was the university. You know who, what happened. So we had to work tirelessly with NSU's legal division et cetera to get everything ironed out. So the first two that came, it was very much a legal faith of not knowing what they needed and what we wanted from them, but it worked well and then that has been a tradition that's carried on until the current day. We actually have students that are in the UK at the moment, who are practicing in the UK, and we up those figures from six to slightly more, mainly because now obviously those are our four schools, so we have a lot more than those 80 students there. So to add fairness to all of those schools, we send them. Previously we sent them from August, when they went to see your clinic or see our cycle, through till February. Now we send our Denver programs on a different cycle, so those students from Denver that's got a slightly different time. So it's a tradition that's carried on for some time.

Speaker 2: 49:37

Yeah, wow, wow. That is a crazy story and I just I'm so inspired by all of that that every person who made an extra effort or like bet on themself or like leaned into fear, like that's just that's, yeah, that's just really inspiring Absolutely. Can you describe a little bit? Because you got off the plane in Tampa and Orlando, sorry. And you were gonna work at Nova Tampa and but now you work for all the schools. Can you explain kind of what your day-to-day looks like or what you're actually teaching for Nova?

Speaker 1: 50:09

Yeah so so myself and another the person who was the lead in Camarventuring, wales were both invited out there. So we both had that unique skill set of ultrasound and kind of mine was more on the regal anesthesia side. The other faculty member that came over his was more on the vascular access side. They were an amazing pig service back in Wales pig line, pig lines, vascular access service there. So I, when we were invited over that individual, went to Fort Lauderdale. I was coming into Tampa and that's how it stayed. That individual's since gone back to the UK because of family reasons. So I'm the only person, I'm the last man standing, as it were, and so we came in the March and actually came on a long-term visitors' visa because I was living with my mother-in-law, who I love very dearly. But when you have you and your wife and two kids living with your mother-in-law in a small three bedroom house with one bathroom, it becomes all of a sudden very different. So we decided we'd come out in the March and then I kind of knew about the job at Nova, but it wasn't formally given and so we still had a process to go through. That took a little bit of time then for us to or for myself to be interviewed to go through the onboarding process and then visas, which was the biggest issue we had. So I came here in March. The third I didn't actually start working for Nova until August of the same year, so kind of five months later I started working. That's a huge expense. Anybody that lives in Florida will know they're going to pay $3,000 a month in rental and they've got two kids, everything else that goes with it and you're not working for five, six months and you soon burn through any savings that you've had. So I started at Nova Tampa, which at the time then was in a small facility outside of the beautiful new building that we've got there, and predominantly teaching. Initially we set up a whole essentials of ultrasound course, so ultrasound, lunged on a seizure, also vascular access et cetera. But we're teaching other things as well. So I was teaching in labs, so doing lab simulation. I've been SLS, a student lecture series where we teach our students to present appropriately and do research. That was very good At the time. Then I was traveling in the semesters that we were doing the ultrasound courses between Tampa and Fort Lauderdale and doing no scores, and then Jacksonville, oakland, so then that was another triangulating up to Jacksonville and then Denver opened. So they'd go flying up to Denver there and basically kind of doing the ultrasound. So in this semester that we're at being now we start doing a little bit of ultrasound education. This is my Denver semester, so I'll start teaching the Denver program doing all of their academic and didactic teaching for regional anesthesia with ultrasound. Then later on in this semester I'll go up to Denver so we could do one-on-one teaching. So I'd go up there for a long weekend period so everybody gets a chance to kind of go through all of their hands-on teaching. Next semester, our summer semester, I'll then flick between Tampa, fort Lauderdale and Jacksonville and then when Orlando comes on board they'll issue Orlando Open. So then that'll be another one I'll be doing for 2025, I'll end up going there. I then took on our lab director, who was with Nova or left Nova, so I was off at the lab director's position. So now I'm lab director for Nova Tampa. So that involves obviously setting up the labs, writing the scenarios, lab final situations, so everything that goes with the day-to-day running of all of the labs. So in this current semester so I'm doing Denver teaching for ultrasound, a lab director, and I'm back to teaching SLS again or proctoring the SLS scenario. So it's wide and varied. So, yeah, that's on two days a week. So I work on a Tuesday and a Friday at Nova doing those things as well as everything else that I do to promote my profession or look at the students, take shadow, as an exception.

Speaker 2: 54:26

Yeah, and you seem so energized about it, like what you just listed feels like so much for me because I'm not in that. I mean that regional world just doesn't feel tangible to me. But I can tell how lit up you are about it and I wanted to speak a little bit about that, like how there are some CAs like myself who would say I'm not skilled at regional anesthesia. I went to school 15 years ago. We had a little bit here and there and I think you kind of even spoke to that. That that's kind of where we used to be and you're part of this movement that's moving us more towards proficiency, at least basic blocks, and Nova is really a model for that. It sounds like in terms of education, and I just I wanted to pick your brain as a CAA to another CAA, like what do I need to do to know more or do more, or like is it too late for me? Like what would you say about older CAAs and regional anesthesia?

Speaker 1: 55:26

Well, I mean, I completely fit into that bracket and I didn't come into this profession until I was old, or as well, and I just think so. There's a few different answers to that. First of all, I think that the more of us that do regional anesthesia, the more patients are gonna benefit. We are in this job ultimately to service our patients. When I first came to America, I was amazed at the lack of delivery of regional anesthesia, because in the UK I was like I used to come to the American Society of Regional and I see a meeting every year, and I'd been awe of, kind of, oh, america, it's the panacea of doing regional anesthesia. And when I came out here and started to speak to people, what I realized was at the American Society of Regional and Aesthetic Meeting it was the same couple of thousand people that were there every year, most of the anesthesiologists and residents et cetera. The same faces and the same people. And when you look into literature and research, and it's the same names on publications et cetera. So it was kind of an exclusive club. That's how I like to describe it. It's a chic thing. You know, the anesthetist strolls in with his ultrasound and he's moving to the left. He takes the pain away in one. The other thing that was starting to me was the opioid crisis in the US, which I did a lot of research about when I first came here, and tens, if not hundreds, of thousands people die in each year mainly because of overdosing on prescription medication or not being able to get prescription medication and then going and drug finding elsewhere so you fracture your ankle or give you percosec. The next thing you were heroin addict. Like how does that even happen, you know? So by taking that pain away and working on that was a great thing that you asked about. How do we learn to do it? Well, I didn't have those skills when I came out of school. I had no idea and, as I said previously, I had to go away and learn it and it's a very steep learning curve. When I first learned regional anesthesia, I learned it with nursing. Later I was doing brachial plexus blots one million, I'm putting it. My assistant came down to 0.3, and the patient's arms jumping around and they're squealing and you're trying to give them more bursa, a bit of pro-profile, and it was just barb-barking my eyes. So then, moving and developing that service made things better. I'm not the only CAA in the US, that's kind of promoting it, but there's not that many drivers from our point of view. Now we should all, and my belief is we should all have a basic understanding. I'm not saying that everybody should do it, because not everybody wants to, but we should have a basic understanding of probably around eight nerve blocks. Those nerve blocks would be able to block. You could do the upper limb, you could do the lower limb and we could do the trunk. So we do those eight limited blocks. Now, in order for us to be able to become competent at them, we have to practice them. So we have to maybe say, right, you know what? There's a lot of abdominal surgery in my hospital or a lot of robot surgery. A tap block would be good for those patients. Let me learn a tap block and then let me do a tap block for everyone and my patients, and when you get proficient in that block, then you can say, okay, that's good. Now I've heard of erectus block, which made me better than a tap block for midline incisions. Why don't I learn that? Then you say, okay, what about an erectus philipne block? That made me even better for that and it's got to help with my breast and you kind of move forward. So my first block I learned was the axillary brachial plexus block, which I think is a complicated block because there's a lot of nerves, a lot of vasculature inside there. Then I learned into scaling because those were the two specialities. Now, depending on where you work, probably a lot of people if they're doing orthopedics, they're doing token the arthroplasties, and we know the adductor canal block is a great block for post-operative pain management in those patients and certainly in my hospital they get a spinal and an adductor canal block and zero opioids. So we're helping do our part to reduce that opioid crisis and giving them good pain relief, early mobilization, allowing physio to be able to work with them. So now we're part of a bigger multi-disciplinary team in looking at those specialities. So you pick the block that is best going to serve this, your patient population, and focus on that. Now, education is the key thing. Back in 2012, when the first American student LA's come over at the same time, I had an idea of developing a teaching program to teach people regional anesthesia, because it was predominantly in textbook form. Now. That involved basically using DVDs or CD-ROMs. You know, you would go to a conference and you'd see something and they'd give you the CD and you'd go home and you'd put it in your computer For the younger ones out there. That's like, you know, a little shiny disk. If it was scratched it wouldn't work. And that's how we shared our learning resources. At the same time, apple released the first iPad and I was fortunate enough that my wife liked me enough to buy me a Generation 1 iPad. I thought, wow, this would be amazing. How do we get that CD-ROM onto this iPad, which is, of course, via an app? So this would be a cool thing. So I went to a few companies and said I've got this idea to produce an app and they said, well, come back to us if you've got anything you know, kind of storyboarded or what you think about it. So we were a big hospital and we had a whole videography department in our hospital. So I went to our videographer and said, fancy, developing an app. And he said I've never done it, I wouldn't know where to start. But yeah, I really want in on this. It's the future, and we created a company called Block Guru and we created an app which is still out there being sold nowadays, and then from the app we created a range of posters, because not everybody had IT at the time or had an iPad or an iPhone, and certainly in third world countries, et cetera, they didn't have access to IT or Wi-Fi necessarily, so we created printed, laminated posters that we could send around the world. Then we developed courses from that and then Block Guru it's not as active as it was because we're kind of split up around the world, but we run those teaching programs. And then when I came to the States, I got in with an anesthesiologist over here and became part of a company called Ultraside Experts, based in Tampa, where we run courses which now we run out of our NOVA, our NOVA University, because all of our facilities are there and it's just about education. The American Society of Regional Aesthesia, the New York School of Regional Aesthesia, nysora, all kinds of names that if you're interested you would know those websites and of course Google, our new Google adducta canal block, and you're going to have however many tens of thousands of videos or literature reviews or whatever. So it makes it less prohibitive for us to be able to do that nowadays, to be able to learn those skills. The prohibitive nature comes in then getting our anesthesiologists to support us in clinically practicing those skills. So we then need to go to them and say, hey, I've learned all about it. I understand my anatomy, my benefits, my contraindications, I understand the local, I understand that last and the treatment of emergencies. Get them to scan and say, ok, well, there's my sartorius muscle, there's adducta lungis, there's adducta mangus, and so as long as we know our terminology and what we're looking at, eventually someone's going to say, ok, the next step is to put the needle in. I'm going to support you doing that and you're going to do one. N equals one equals two equals three, and it escalates into that learning curve where we're doing that now. Another part of restriction on our behalf is the is the nomenclature and the interpretation of how our role in regional anesthesia is written into our guidelines with the state and on a lot of respects it says that the literature or the language will be assist, assist with or assist in performing regional anesthesia. So assist with performing regional anesthesia would get used against us because to assist with performing it, then that would be, you get the drugs or you'll get the needle, not actually do it. But my interpretation is I'm assisting my anesthesiologist by performing that. So you know, as as we're all supervised by our anesthesiologists and we will always be supervised in that respect in my hospital we're performing our regional anesthesia, but it adds some limitations onto the way that we can do that and we shouldn't be exclusively prohibited from providing those skills, because there is only one person that is at disbenefit of us not being able to provide those skills and that's our patient. And when we fight between our specialties of our nurse and our nurse anesthesia colleagues and our AAs and anesthesiologists, maybe we've lost a little bit of insight into the fact that the patient's going to benefit. The more of us that do regional anesthesia competently, the more patients that are going to be offered that service, the more we can help with opioid, opioid crisis pain control, et cetera, et cetera. So very passionate about reading the situation I love it.

Speaker 2: 1:05:00

I'm soaking it all in. There's a few different things that stood out to me. One of them is I just want to say thank you for breaking down the practicalities of how someone who's not done regional in a while but wants to to better the type of anesthesia they can deliver and better serve their patients, participate in a reduction in the opioid crisis. How they can actually boots on the ground, make that happen. And it sounds like you're working at a hospital. You're doing some sort of surgery you've identified the patient would benefit from regional. You're going to educate yourself in the ways that you've just laid out, using the resources that are available to CAAs and to everyone on Google, and then you're going to take your education to the anesthesiologists or to management and say this is what I think would be best for our patients. I'd like to be involved in this new implementation. I think it's a path I see forward. How can we work together to make this happen and be persistent with it and be dedicated? And, you know, want to do it. I just think people need to want to do it and, as you said also, maybe you don't want to do it and know that like okay, I'm going to go to a place where maybe that expectation isn't there for me and maybe patients are getting regional. But it's 100% done by the docs and I'm okay with that.

Speaker 1: 1:06:18

It's just changing that mindset, just changing the kind of just because we've always done something this way, we all know in medicine that that is probably not the way to deal with medicine. You know, this is the way I do it. We've all had mentors. We all know people that don't like that. I am a huge sponge. If I get a student come to me and say, hey, I'm just rotating from this hospital and we did this at this hospital and it worked really well, I'll say let's try it. What have I got to lose? Let's try it. Classic example yesterday Last week I had a student send me an email with their logbook for the week and said hey, I did a long case and we used a product called an easy blocker. I don't know if you've heard about it, I don't know if you've seen it, but my main job plan, clinical use thoracics, all double looming tubes. If we can't get the double looming and we have problems, we just suffer with those. We have some uniblockers which don't work to a great extent. So I researched, found the blocker, the easy blocker that they were talking about. They emailed me and yesterday we trialled that system in the thoracic surface yesterday and they worked fantastically well. So I could have been like another balshy, grumpy person and said oh, I'm not like a student, tell me anything, I don't know anything. Instead, as a team, we bought that product and now said you know what? These could absolutely replace double lumens and the problems that they create, the consequences of that Precedex. We don't have dex metatomide in the UK. It wasn't when I left the UK. We all know kind of include to use it Again. A student said to me hey, we use precedex in our lumegry where I was in my last rotation, so okay, let's try and use that. Now I can literally do opioid-free thoracic surgery now by using multimodal analgesia and using X-Bereal intercostal nerve blocks. How great is that that we've changed the service. Historically this is how it was done and now we're developing new skills and pathways and services and helping kind of move analgesia into a new form and not relying on those opioids that we always did historically. I was guilty of that. Everybody in the UK would get 100 offensives and 10 of morphine for the most part. I can't remember the last time I gave anybody any morphine and if I use more than 100 offensives, then something's not working somewhere.

Speaker 2: 1:08:45

I just hear something that I believe is true as well, which is a flexible anesthesia provider is the best anesthesia provider. And I also wanted to just question you what is your relationship with curiosity that word kept coming to mind that you just seem to have a curious nature that kind of pushes you forward. It's something that maybe not everyone has. I don't know if you ever thought about that word before in your life.

Speaker 1: 1:09:16

No, but now you say it. If you spoke to my wife I'm sure she would say I'm very curious, in the respect that my hobby is kind of flip backwards and forwards. My interesting things is always kind of changing. I'm sitting in this room now. Right next to me is a 3D printer that my son had for his birthday, and between us now we're like, oh my gosh, you're 3D printing everything that we possibly can. It's like kind of a new thing that we're getting into. And that's the same in medicine for me. I was constantly looking at those things. Some of it was dictated by, in all fairness, that I could travel the world, go into conferences. So if I was interested in regional and I'd say, okay, when I'm going to Vegas or I'm going here there, all across Europe, to go to the European meetings was a great kind of learning, kind of mini vacay, as it were, to go and learn and pick things up, reading the journals, looking at what the latest literature was. So I am very curious to see kind of where we can go, what's moving forwards. You know how we can develop these skills that you alluded to know those are this great kind of setup for regional season which we absolutely have. We have block rooms. We have every single site has their own ultrasounds that the students can use. We have needling phantoms from some great companies a ton of resources that our students can use, and I know not all schools have that and but eventually maybe they can. Maybe we can work as an association to develop some type of online learning system. You know, I think that's a. That's a great thing that we should be looking at is promoting as a national association through our quad a and saying, okay, well, you may know that I work courses pretty much every quad a, I try and run a regional course there. So, whether it's vascular access because you may say I've got no interest in doing regional anesthesia, or really don't want to learn it, or actually my hospital doesn't want me to do it, but I would love to learn how to use ultrasound correctly in order to be able to do my a lines more proficiently, or central lines, or just difficult IVs. So that's another course that we teach and I don't expect everybody to do regional, but I absolutely expect that we should all now have a great understanding of how to use an ultrasound and that's going to keep us within that market. It's going to make us marketable as a is and other professions are not going to overtake us because they've got those skills. We should be able to offer those skills and I know in the US it's very different. You know, I'm saying, or maybe the quad a should develop these courses and we should have courses that people come into. What normally happens is me as an individual, we'll create a company and then I want to make money out of it. I don't want to make money out of it and I don't want the stress of doing that as an extra job. Yeah, we definitely need some way of kind of promoting that.

Speaker 2: 1:12:12

Yes, I think the capitalistic nature that you're maybe talking about that wasn't there in the UK, where that was funded and you were creating these things, you had almost more of a creative freedom, possibly to feel like I can do this because it's needed and it like fuels me, as opposed to this thing in the United States has to be a business that I'm going to sell. Oh, mark, I could go. We could talk a lot about that, the dichotomy there. I think I want to answer a question that likely our listeners are asking themselves right now, which is I'm a practicing CAA, can I work as an AA in the UK or in England? And similarly, I'm a current AA student. Can I do an away with rotation in England?

Speaker 1: 1:12:57

Okay. So the short answer to the first, the first question you are a practicing AA. Can you practice in England? Yes, so there's no. To my knowledge there's no American AA's that have crossed the ponds to go work in the UK, but there is one Canadian AA. Now Canada also has AA's between the provinces. The role is somewhat different than I don't want to offend the Canadian AA's there, but certainly there's more autonomy in different provinces and that's the knowledge that I've had in my limited research to that. I'm happy to be corrected if people want to reach out and tell me a bit more about the Canadian AA system. But the Canadian AA was married to somebody in the military. They were being posted to the UK and basically went to the Royal College of Aesthetics Remember, that's our kind of our body that runs our education and said, hey, this is what I'm doing. They were putting in touch with the university that said, Well, if you can get a hospital that'll sponsor you, then you can come over and we'll do an abridged version of our course for you. And from my knowledge that person is still practicing in the UK. So if an American AA wanted to go work in the UK, that would be. Their route would be to contact them If somebody wants to do that. People have reached out to me. I have had some American AA's who, in a very similar situation to the Canadian AA, has a partner in the military and they're going to go and be stationed either in Europe or in the UK, predominantly in the Air Force, to get the American Air Force. And so they will say, Well, I still want to practice, how do I do that? So they reach, they could reach out, I could introduce them to the right people and the potential is there for them to go and kind of bridge version of the program from the just brush on in case there's any, any British, UK AA's that are missing into that. The process coming the other way is not as easy because there are visa issues, sponsorship issues etc. It becomes very, very, very difficult. Hence the reason there was just me and one other provider that came over. The other provider has since gone back to the UK. When I my UK colleagues, I was actually speaking to somebody just last week who was introduced to me from the UK and it's like I really want to come over, really want to work over this. We had a good conversation and then eventually they're like Okay, well, I'm going to have to kind of climb over hot coals up and down the size to try and make this work. It becomes very, very difficult from student point of view. Nobody's currently the only university university that has an international rotation. So when our first students come in 2012, we had no documentation for them. We didn't know what to do with them. So we had to work with that legal team. So they had insurance is based through an issue to be able to come over. It was self funding, so they paid their own flights. That are accommodation, etc. Etc. Like like any current student that rotates around the US. You know, they know that Nova students go. They could be in New Mexico I'm in it and they'll be in Nevada, then they'll be up in Wisconsin. So you know, we like to give our students a good variety of movement, so they're kind of used to investing that money. They have to apply from a Nova point of view and they are interviewed. So bring over the preceptors from the UK, come to quad a every year and they interview that group of students and then they select their group. If it was a different school, you know my advice is to work, work, reach out to the associations and just ask if there's any other hospitals that want to do it. There's a big political underton in the UK at the moment, so it's not a good time for AA's and PAs in the UK at the moment. So, you know, it's kind of like that They'll settle with things that are going on with which we can discuss, if you'd like to, and then see how things are over the next year or so and let's see if that's a possibility.

Speaker 2: 1:16:59

Oh, mark, we could totally get into all of that, but I think maybe let's hold that for another conversation, because there are so many pieces of you that we've hit on this that I think are really going to resonate and inspire different people or different people who are in their CAA journey at different points. I wanted actually to get to my sort of big last question, which is the ethos of this podcast, being that I believe the CAA profession is a road to a unique chance at building the life that you exactly want Like living. Your life by design is accessible to a CAA in a way that it's not accessible to, I don't believe, any other medical profession, and I'm wondering what your relationship is with that statement and, if you would agree, has that resonated for you in your life?

Speaker 1: 1:17:53

Yeah, absolutely. I don't know if I've ever met an AA on either side of the world who has ever said they hate their job, and I can't say the same for other specialties. So it's such a rewarding job and that's a very clichéd answer that I want to help. It's the Miss World Answer, isn't it? Oh, I want to work with sick animals and children. It's cliched in the respect that we are providing an amazing service. Patients are entrusting us with their lives. We are there to deliver that service, to keep them alive, to make them pain free, to make them not feel nauseous, to do no harm. So it's a great, rewarding career in that, across the states, it's rewarding in the respect in that you can choose where you work, what you do. You want to work in a surgery center and do inguinal hernias and lap coalesce for the rest of your life and you know, just deal with those young, fit, healthy patients for saying, you can do that. If you want to specialise in Peds, if you want to do pediatric heart transplant, you can go and choose those specialities that are appealing to you and satisfy your need within your, within your job plan, of course, then we have our hours, so you can do eight, ten, thirteen, twenty-four, whatever people decide to do, and some people are going to do. You know, I know colleagues that work a week on and then they have kind of like two weeks off and they can either pick up to do their local work or travel or do whatever they want to do in that time. So it allows us that and of course now everybody. There's no hiding from the salaries that we receive in anesthesia. Financially we're in a gifted situation where it gives us a great salary, where we are able to afford to pay off the student loans easily, living nice houses in nice areas, drive a nice vehicle, if that's what you want, or if you want to travel. You know, I know lots of colleagues that their main driver is to save up some money and then go travel and see the world and do these amazing things. They put us in a privileged position where we can, where we can do things. But on the financial side of things we also have to kind of. You know we've got to where we are by paying our money and doing our courses. What we should be doing afterwards, when we're earning these big salaries, when we paid off that money, put some money back into our profession. The way that we can do that is to be members of our professional association. So our national, quite a in our state organization do not work without funding. I donate to my organizations and I just do it via a standing order. So I don't even notice that that money goes out of our county. And you know it's what? It's? Less than an hour's overtime. So for the most of us we're able to provide, you know, a good donation to our organization. So there are the people that got us to where we are now. If you're going to take a job in Nevada, it would not have happened without the hard work of the people that worked tirelessly to create that state organization and represent our profession in there. You know being belittled by the people that were opposing us, etc. So if you want to work in Nevada, put some money into their state. If you want to help with our, our quad, then help with that. If you don't like what they're doing, then put yourself onto that group and say, okay, I'm going to stand for one of those posts, I'm going to stand for a director post or a committee post and have your input. You know, unless you are actively involved in your state or your national organization, then you can't have your individual voice and we've probably all got different individual voices that we want to share and spread out. So if you're not a person that wants to be involved at those levels, then fine, just do it by supporting them financially. We're fighting against groups that are not fighting against. We are trying to use the word fighting. I don't like to think of this fight and we can. We could all, we could all work to get that in harmony if we chose to do that. So the better outcomes for our patients. Instead, what we choose to do is to fight and battle against each other because we think that one is better than the other, which is absolutely not correct for everybody that's worked with each other as part of an AC team and for the data and research that has been done that shows that the AC team is one of our safest modes of anesthesia delivery. So my little rant is kind of when you get out of school, when you've got a job, give back, help, support your professions and then you know, be an active part of your profession and promote our role. We are, we are amazing, but we are more amazing as a group of people than we are as a small group of individuals, like the work that you're doing, marriage and just promoting everything, getting everything out there. The other, the other people that are kind of chibilly and Taylor and Anastasia Sal and gender noses we have worked. Just everybody is currently kind of pushing us. We've gone from the best profession that nobody knew about to a profession that everybody's knowing about now.

Speaker 2: 1:23:01

Yeah Well, I just really wanted to offer you gratitude as well, because the thing that the other content creators in our profession, the thing that they're doing, is also the thing that is your strong suit, which is seeing a system as it stands and thinking I want different. How can my unique skill set come into this existing system and turn it on its head or change the piece of it that doesn't resonate with me? And you've done that. It's just like you've blown that idea up. I mean, there's just so much good work happening with CAAs and regional anesthesia because of you, so I just wanted to never one say thank you for the work you're doing and also to really point out that, so that if the listeners are thinking, gee, there's something in the CAA profession that doesn't sit with me well or doesn't resonate, or I want to change, you are the person that is supposed to change it. Our profession is small and it's this beautiful privilege to know that I have the power, as one person, to change, to make big change, which is likely true in the bigger world as well, but inside, our profession just feels so much more tangible and people like you are showing us the way. So thank you so much, mark, for being here and sticking with this recording. Behind the scenes had a bunch of issues and I can tell that today was the day we were supposed to have it, because what a beautiful conversation, just full of your wisdom, that everyone else is going to get to hear If there's any perspective CAAs out there or current AAs who want to move to the UK, or somebody who's thinking I've got a follow up question for Mark what's the best way for someone to get a hold of you?

Speaker 1: 1:24:39

Yeah, so you can find me on Instagram, you can find me on Facebook. I'm old fashioned, you can email me and you can put my NSU email address and go into the post script notes. So I'm happy for you to reach out to me and I will get back to you. And you might not be straight away and I kind of have kind of a pro-former reply that I have because I've done this so many times and especially from the UK people contacting me. I kind of have like a standardized email that I can let people know, but I'm happy to try and help anybody really. You know, either get into the profession or, you know, we get questions about things and we've got to look after each other, we've got to grow our professions and we've got to support we don't want to eat our children. So you know we absolutely have to be there to kind of support them and try to help them out in the UK.

Speaker 2: 1:25:31

Great. Thank you so much. Yeah, I'll put your Instagram handle. I don't know your Facebook, so I'll have to give that from you and I'll put your email, your NSU email, in the show notes, if anyone's wanting to follow up with Mark. I think that's it, mark. We finally did it and I'm just so appreciative of you. So, yeah, and I just I can't wait to meet you in person at the Quad A this year and just continue this friendship and relationship that we've developed. So I really appreciate your work and thank you Well thank you.

Speaker 1: 1:25:58

Thank you for inviting me and thank you for everything that you do for our profession as well. I saw you last year running around interviewing everybody.

Speaker 2: 1:26:06

Yeah, I didn't know you last year.

Speaker 1: 1:26:08

Exactly, yeah, I still saw you. So, yeah, I mean that's great and it's what we need. We need more of us promoting our profession and getting out there, because if we don't fight for ourselves, nobody's going to fight for us.

Speaker 2: 1:26:22

Yes, yep, all right, Beautiful place in. Thanks, mark.

Speaker 1: 1:26:25

Thank you.

Speaker 2: 1:26:27

I hope you loved this episode. If you want to connect and discuss anything that we mentioned here in this episode, of course, check the show notes for all of Mark's information. If you have a question for me, the best place to get in contact with me is over on Instagram at AwakendAnesthetist. Instagram's really the only social media that I routinely show up on. I'm always checking my direct messages and it's just been a really nice, easy way to connect directly with this community, so I encourage you to follow me over on Instagram at AwakendAnesthetist. As always, if you loved this episode, something you can do that really helps the podcast is to share it directly with another CAA in your life or an AA student or someone thinking about going to AA school. Every time someone inside our community says something good about this podcast, it really creates a momentum for more CAAs to be able to gather and share new information and do other things that maybe never seemed possible for CAAs, but once we're gathered together, we find a way to make them happen. I'll be back in February with another process episode. You can always join the AwakendAnesthet newsletter community, which is just a more intimate community. Every month, I send out a newsletter that's got resources, ways to connect some wellness resources, as well as a new offering called Making Connections, which is really for the AA students and the practicing CAAs out there. It's a new connection group that I'll be offering once a month virtually, and if you're part of my AwakendAnesthet community, you'll be receiving the emails to join that group and be a part of Making Connections. However our paths cross in the future, I hope we get to connect and let's talk soon. Yahoo, mark, we did it. Oh my goodness.